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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 6: Claims Filing : 6.1 Claims Information : 6.1.5 HHSC Payment Deadline

Payment deadline rules, as defined by HHSC, affect all providers with the exception of LTC and the DSHS Family Planning Program.
The new HHSC payment deadline rules for the fiscal agent arrangement ensure that state and federal financial requirements are met. TMHP is required to finalize and pay claims within a determined time frame (see table below), based on provider, claim, or eligibility type.
The following table describes the new payment deadline rules:
Medicaid/Children with Special Health Care Needs (CSHCN) Service Program payments, excluding crossovers, cannot be made after 24 months from each DOS on the claim (discharge date for inpatient claims.)
The payable period for all refugee Medicaid payments is the federal fiscal year (October-September) in which each DOS (discharge date for inpatient claims) occurs plus 1 additional federal fiscal year.
The crossover file create date is the date in which the file is received by Medicaid. The state has 24 months from the create date to pay the crossover claim.
The payment deadline is derived from the client’s eligibility “add date”; to allow 24 months from the add date for the retroactive Supplemental Security Income (SSI)-eligible client.
Claims and appeals submitted after the designated payment deadlines are denied.
Providers may appeal HHSC Office of Inspector General (OIG) initiated claims adjustments (recoupments) after the 24‑month deadline but must do so within 120 days from the date of the recoupment. Refer to subsection 7.1.5, “Paper Appeals” in Section 7, “Appeals” (Vol. 1, General Information) for instructions. All appeals of OIG recoupments must be submitted by paper, no electronic or telephone appeals will be accepted.

Texas Medicaid & Healthcare Partnership
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